Fatal Care: Hundreds known to Alberta child welfare authorities died in the care of their parents. Why?

A father, who can only be identified as Merle, visits the grave site of his infant daughter at the Paul First Nation. The Journal received records for 287 children known to the provincial government who died between Jan. 1, 1999 and June 8, 2013.

Photograph by: Ed Kaiser
, Edmonton Journal

The name of the child in this story has been changed to comply with an Alberta law that prohibits identifying children who have received government care.

Ten-month-old Jenny drowned in a bucket of home-brewed hooch last year, and her tragic story was never told.

Not by her mother, who was charged with criminal negligence causing her death; not band officials on the northern Alberta Fox Lake Indian Reserve, population 1,800, where Jenny lived and died.

Not by the RCMP K-Division major crimes detective, who omitted the horrific details from the written charges — the only public record of Jenny’s death.

Not by the RCMP brass, who issued a brief news release and refused to divulge more information.

Not by the caseworker or supervisor at Little Red River Cree Nation Mamawi Awasis Society, the child welfare agency that was investigating reports that Jenny might not be safe at home with her family.

Not by the provincial Ministry of Human Services, which produced an internal report into her death barely two pages long.

Not by Alberta Justice, which has scheduled a one-day trial in a remote northern Alberta courtroom next month.

Alberta’s Child and Youth Advocate has not issued an investigative report. No fatality inquiry has been called.

Who speaks for little Jenny?

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Nearly 500 children like Jenny have died in Alberta over the past 13 years.

All of these children were known to child welfare authorities, but they remained in the care of their parents, where they died.

In many cases, the deaths were natural or not preventable; some clearly were not. In some cases — like Jenny’s — child welfare workers had received a report of neglect or abuse, and were in the process of investigating when the child died.

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In others, caseworkers investigated a report and determined the child was safe at home, with ministry support and supervision. Sometimes, the child was apprehended and later reunited with his or her parents. Often, the file was closed.

Between Jan. 1, 1999 and Sept. 30, 2013, at least 476 children died while “receiving services” from the ministry, more than triple the 149 who died “in care” over the same period.

Unlike deaths in foster care, the death of a child receiving services is not subject to mandatory review by the medical examiner, the Ministry of Human Services quality assurance council, or Alberta’s fatality review board. Fewer than one in five is subject to an in-depth internal review.

Not a single one has ever been publicly acknowledged in a government annual report.

“We have all sorts of checks and balances if you remove a child (from their home),” says Robert Fellmeth, executive director of the U.S.-based Children’s Advocacy institute, which studies child welfare deaths. “The problem is that in the other direction, there is nothing. … We need to have some check on failure to remove, on failure to protect, and the only check we have is examining these deaths.”

It’s crucial to analyze these cases – studying what child welfare workers knew, what steps they took, and the problems they encountered – in order to identify what needs to be fixed to prevent future deaths, he says. And that process needs public scrutiny.

“That’s the only check you have … and you’ve got to have it. The public, in a democracy, has got to have it,” Fellmeth argues. “But the people who are involved have a bias against disclosure. ... It’s because they feel that everybody makes mistakes, hindsight is 20/20, and they’ll be unfairly condemned for what happened. My answer to that is, let us be the judge. Let’s at least talk about it.

“Because the only check we have is your failure to act, where death results. We don’t know anything else.”

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Details on the deaths of these children were released to the Edmonton Journal only after a four-year legal battle with the province. In August, the Journal received death records for children who died while in the care of the government, which lead to an investigative series in November by the Edmonton Journal and Calgary Herald into the child welfare system. Then in December, the province released to the Journal the death records of children who were not in care, but were receiving services from the government.

Those records showed 287 children died while receiving services.

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However, earlier this month, under pressure to be more open and accountable about its child welfare system, the province publicly released figures for the deaths of all children who had come to the attention of the ministry – those in care, receiving services and more. At that press conference, the province said 476 children died while receiving services, 189 more than what was reported to the Journal.

The Journal asked why the 189 reports of death were missing; a ministry spokeswoman said it’s because there are no such reports for those 189 children.

We based our analysis on the 287 records we have.

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Nearly half of the 287 children who died receiving services were babies aged two and under.

Of those 139 deaths, 36 died from Sudden Infant Death Syndrome, nine died from asphyxiation, and six died from cranial trauma. Two died from dehydration, including a two-month-old infant from Saddle Lake whose file was opened and closed three times because the family was transient and overworked staff couldn’t keep track of them.

One in three who died were teenagers, 98 in all. Of those, 22 died in a collision or were hit by a car or train, eight overdosed and four died from hypothermia.

Suicide claimed 29 of the teens, along with three preadolescent boys. In the case of one 10-year-old boy who died by suicide, investigators concluded that “despite repeated, often lengthy investigations, a file was never opened. Decisions to close investigations appeared to be made based upon assumptions surrounding the involvement of other agencies.”

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Across all age categories, the manner of death was unknown in 80 cases and 56 deaths were natural, from disease or illness.

Officials rarely investigate the deaths of children who die while receiving services from the ministry.

Alberta’s Child and Youth Advocate is the only external, independent body with the legislated right to review their death records; he has had that power since 2012, but has yet to publish an investigation into any of their deaths.

Under Alberta law, the Fatality Review Board does not conduct mandatory reviews of all deaths of children receiving services. The province has held six fatality inquiries into these deaths, and all but one looked at fatalities that made headlines — among them a baby who died in the care of a 10-year-old babysitter, two boys killed by their fathers during custody battles, and a boy shaken to death by her mother’s boyfriend. Caseworkers had asked the boyfriend to submit to a criminal record check, but he refused.

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Alberta’s child welfare system is designed to keep children with their families wherever possible, and the decision to apprehend a child is not an easy one.

After a report of neglect or abuse, caseworkers conduct an initial investigation. If they find the report is substantiated, they order a safety assessment, which determines what kind of intervention is warranted.

At this point, the caseworker and a supervisor decide whether the ministry will provide in-home supports or apprehend the child and place him or her in foster care. Sometimes children stay at home with ministry support, are later apprehended, and later still returned to their parents. Sometimes, this cycle repeats itself, over and over again.

So, when a child dies, there are often many questions: Could caseworkers made different decisions? Were signs missed or steps skipped? Did caseworkers follow policy and the death still occurred? Or was the death just not preventable?

“There are layers of complexity here that many people don’t understand – this isn’t a simple decision,” says Jackie Sieppert, dean of the University of Calgary’s faculty of social work.

“There are lots of reasons why children need protection,” he says, such as physical and sexual abuse, emotional maltreatment, addictions issues, poverty and homelessness.

“The social worker has to make sense out of all of those pieces, and that’s incredibly complicated, sensitive and difficult to do,” says Sieppert.

“When you look at that balancing act, it becomes a real Catch 22 for the workers. If they remove the child and the child moves into our system, there are lots of implications for the child and the family. ... If the social worker doesn’t remove them and something happens, obviously we end up talking about very tragic stories.

“It’s really complicated, and probably some of the hardest work that happens in our society, and the people who do it are rarely noticed unless something really bad happens.”

Lori Sigurdson of the Alberta College of Social Workers says exercising this extraordinary power and responsibility can take its toll.

“It is a tremendous burden on staff, when they are making these decisions,” Sigurdson says. “Because we are dealing with human beings, there is no cookie-cutter approach. Every situation is unique and dynamic.”

Sometimes, Sigurdson says several families are in crisis at the same time, and front-line workers are balancing advocacy with report deadlines, budget concerns and paperwork. “It can be an onerous process just to get the supports these families need.”

Between 1999 and 2013, the ministry conducted internal, in-depth reviews into 45 of the 287 cases in which a child died while receiving services. Those reviews resulted in 190 recommendations intended to prevent future deaths.

A Journal analysis of these heavily redacted reviews shows that in many cases, child welfare workers made multiple mistakes.

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The most common error was failing to gather enough information about the child or the family. In 25 of the 45 cases, the review revealed caseworkers didn’t conduct appropriate assessments, failed to make collateral contacts, or didn’t followup.

In 23 cases, they made errors in reasoning: they focused on the needs of the parents instead of the child, made assumptions, or didn’t effectively plan for the child’s future.

Other common mistakes included poor documentation — like failing to flag key issues — or failing to collaborate and share information with other agencies, like police and schools. In 14 cases, staff were overburdened or poorly trained.

Experts say statistics like this are best used in aggregate, to identify trends in casework practice that can be addressed system-wide.

“There’s no value in using (information about mistakes) in a public forum to discipline individual caseworkers, that’s best left to internal agency practice,” says Theresa Covington, director of the U.S. National Centre for Child Death Review.

“You need to be smart about making (investigations) about the system. … If you can move the needle beyond outrage and anger to ‘what can we do to make the system better for kids,’ there is value.”

However, that doesn’t happen in Alberta. There currently is no mechanism for tracking, monitoring or implementing the recommendations from these kinds of internal reviews.

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The only study of Jenny’s life and death will take place in a courtroom, at a trial to determine whether her 32-year-old mother is guilty of criminal negligence causing her death.

Sources say the judge will hear that Jenny was at home with her mother, siblings and several other adults on May 29, 2013, when she fell into a “brew bucket” and drowned.

Some time later, one of her siblings found her. It’s not clear how much time had passed.

The report of death released by the government says Jenny’s mother rushed her to the Fox Lake Nursing Station, where she “was declared deceased a short time later.”

Alberta Justice says the trial is slated to begin on Feb. 25 in the Fort Vermilion Provincial Court, 650 kilometres north of Edmonton.

The charges against Jenny’s mother read as follows:

“On or about the 29th day of May, A.D., 2013, at or near Fox Lake, in the Province of Alberta, did by criminal negligence to wit: failing to provide adequate child care, cause the death of (Jenny), contrary to section 220(b) of the Criminal Code.”

If she is found guilty, the maximum penalty is life in prison.

In the context of a criminal trial, the judge is not expected to consider what might have been done to prevent Jenny’s death, or to make recommendations that might prevent similar deaths in the future.

A father, who can only be identified as Merle, visits the grave site of his infant daughter at the Paul First Nation. The Journal received records for 287 children known to the provincial government who died between Jan. 1, 1999 and June 8, 2013.